After the Japan Times published an editorial criticizing the World Health Organization ranking of Japan's healthcare as best in the world, my boss, Mr. Wocher, wrote a letter emphasizing further the shortcomings of Japanese healthcare. The following is the letter, as submitted to the newspaper.

Greetings!

As newspaper professionals, I know you will respect my privacy and confidentiality in communicating to you regarding the Editorial that appeared in the Japan Times on 26 June 2000.

I read with great interest the editorial - How healthy is 'healthiest'?. I am of the opinion that you are absolutely correct, but do not go far enough in debunking the myth that Japan's health systems are first rate. In most discussions of Japan's health care delivery system, the discussion of quality is almost an afterthought. Of the five factors cited in the WHO report ranking the Japan health system "best", the most overrated is of that of life expectancy. Diet, low violent crime rates, statistically insignificant HIV rates, climate, social behavior, and numerous other factors unrelated to physicians and facilities are mostly responsible for life expectancy, and it is always correct to point out the excessive credit given to the health system.

Regarding access, Japan has a land mass roughly equal to the state of Montana in the United States. If Montana had 10,000 hospitals and 87,000 medical clinics, many of which are mini-hospitals of 19 beds or less, we would be shocked at the density, but here, a clinic or hospital on almost every corner, is normal and unquestioned. Some would say that supply creates its own demand. On the three aspects of responsiveness, financial contributions, and fairness, high marks are assured, but they are, in my opinion, lowest common denominator characteristics.

It is indeed surprising that the WHO gave such high marks to a health system that is characterized by a one hour plus wait to see a physician for 5 minutes with an additional wait of more than an hour for prescription medications rates that are highest among developed countries. This in light of the fact that a huge number of prescription drugs are domestic only, unknown outside of Japan, and whose efficacy is not internationally attested. One only has to visit the waiting room of a large university hospital to learn that patients in Japan see their physician, on average, three times more than in many other developed countries, averaging almost 15 times a year. Since prescription medications rarely are prescribed for more than 30 days, this ensures a repeat visit monthly, for which the patient and health insurance scheme is charged.

Regarding inpatients, Japan is know for the longest length of hospital stay in the solar system, yet upwards of 35% of patients are discharged just prior to Golden Week and O-Shogatsu, who ...miraculously seem to get better. Taian (every 6th day), is also an interesting feature, overiding best clinical judgements on when a patient should be discharged. These do not appear to be characteristics of a system designated best by the WHO.

Surprising too, that WHO would rate a system best that does not credential or privilege providers of care. Credentialling is a process that looks at a physician's qualifications, and privileging is the granting of permission to do things that the physician has demonstrated he is qualified to accomplish. Both processes are absent here. In fact, physicians here are licensed for life, with no requirement for continuing medical education, or license renewal. Nurses are similarly licensed without these requirements, as are all other licensed providers of care. Driver's licenses and pilot licenses require renewal procedures. Is it not odd that a medical license does not require renewal?

Japan's health systems are absent any required accreditation also, so the variation between facilities is quite great in the absence of minimum standards. Most hospitals here do not have functioning quality assurance programs, effective peer review, and lack any real infection control programs. The only qualification to be the CEO of a hospital in Japan is the Medical Degree (M.D.), and Japan is absent any undergraduate or graduate programs in healthcare administration in the university systems.

With the admission by nurses in Tokyo that more than 67% have made medical errors on the job, and with only 10% of hospital department heads reporting medical errors to the Ministry of Health and Welfare, it appears that risk management programs are not a high priority for implementation either. Most nurses are not university graduates, and are recruited just after high school. With hospitals being complex in terms of technology, one can draw the conclusion that education is a key factor in providing the level of sophisticated care required today. Nurses in the United States, as an example, are almost always university graduates, with almost 30% having masters degrees in such specialties as critical care, trauma, patient education, and others.

Surprising also is that high marks were give to a system that permits staff, visitors, and patients to smoke in hospitals. With the mission of health, allowing patients to smoke seems ethically contradictory. However, when the fact is that more than 25% of nurses smoke, and more than 50% resist a no smoking campaign designed to make hospitals a smoke free environment, it is clear that apathy prevails. Of course, we all know that the Japan Tobacco lobby bullied the Ministry of Health into withdrawing numerical targets for reducing smoking by adults, because this was reported in the Japan Times also. Perhaps we should not be so surprised, since the Ministry of Finance is the largest shareholder in Japan Tobacco, the nation's only cigarette manufacturer. And again, not surprisingly, smokers and non-smokers pay identical premiums for national health insurance.

Again surprising that this "best" system still does not embrace informed consent, preferring, as an example, to disclose a diagnosis to the family instead of to the patient. We all know that the Japan Medical Association pressured the Ministry of Health to withdraw legislation that would require physicians to disclose the contents of the medical record to patients. This too, was reported by the Japan Times. The patient as a spectator, not a participant in his or her healthcare, in my opinion, is an outmoded practice.

In the Japan Times not too long ago, you reported in an editorial that more than 40% of hospitals had less than the required staffing levels, and that about 5% were staffed at less than half of the required levels. Yet, you did not call for disclosure of the names of facilities to the public. What is your position on patient/public advocacy? When the ratio of nursing staff (currently 1 to 4 caregivers/inpatient) was recommended by the Ministry of Health and welfare to be increased to 1 patient to 2.5 caregivers, it was reduced to 1 to 3 because of opposition by the Japan Medical Association. For reference, 1 to 2 and 1 to 1 is common in many developed countries. Since the LDP is in bed with Japan Medical Association, perhaps this should come as no surprise either.

The WHO apparently did not review a terribly flawed brain death law here that has resulted in, most sadly, very few heart transplants, and will not permit children under 15 years of age to be recipients of this common life saving procedure. Health inequality was one of the criteria used in ranking the system as best. The fact that it took a 30 year history of successful heart transplants in other countries to finally arrive in Japan, should be embarrassing to such a highly technical and advanced country. Still, almost none are performed here.

There are many, many more reasons and common examples why the designation by the WHO that Japan's health system was ranked best, is simply not true when viewed more broadly. Your statement that "The WHO specialists who find the Japanese so healthy would be well advised to look more deeply into the situation here" is particularly well said. The main point of my communication to you is that the media can do so much more in educating the public to the shortcomings of this health system, in an attempt to improve it. The late Dr. Morohashi, former President of the Japan Hospital Association, writing the Japan Hospital Association Journal not too long ago (1994) said "It is not for such a rich nation to be content with a medical service that is cheap and inferior" I believe he was correct then, and his statement is still correct today.

Gentlemen, why don't you open Pandora's box completely about the true state of Japan's health care system? The public has been in the dark to long.